Fighting dengue: Too many questions, very few answers

Dengue management is comparatively routine work, but it has now become complex because Delhi was unprepared.

A view of Hindu Rao Hospital's dengue ward. Dengue continues to be rampant in New Delhi. (Saumya Khandelwal/ HT Photo)

The dengue deaths in Delhi have brought to the fore the apathy and ineptitude of the city’s hospitals. They have also exposed the acute absence of coordination between those responsible for health care services and the people.

The dengue epidemic in Delhi is still to peak: It is only by mid-November that the visitation from Aedes Aegypti mosquitoes that spread dengue will end. So unless and until there is clarity about response and responsibility, the number of cases and deaths will spiral, not just in Delhi but in other states too. In fact, of late, there has been an increase in the number of dengue cases across Southeast Asia. The World Health Organization has put out several preventive strategies that are being used by other countries, underscoring the point that dengue epidemics are an indication of the failure of a country’s public health system.

The preventive measures undertaken by the three municipal corporations of Delhi this year have been abysmal and we must seek answers to several questions: How many sanitary inspectors are available for each of the city’s 272 wards? How many institutions and individuals have been fined for ignoring mosquito breeding on their premises? What is the amount of fines levied on them each month? How many places with stagnant water have been covered or treated? What is the ward-wise result of anti-larval measures undertaken in July, August and September? Did the city’s health department provide resources on a normative basis for insecticides, wages and test monitors? Did the officials take notice when the preparation for the dengue season was found unsatisfactory? No one seems to have hard data or credible answers to these questions.

Instead, all we hear are persistent laments about the non-cooperation of private hospitals and implausible claims of increasing beds (sans commensurate medical manpower). This quest for adding more beds is diverting attention from the important referral and case management issues. Delhi’s health department had the responsibility (starting June 2015) to identify tertiary and secondary care hospitals (both in the government and private sectors) and link them for managing dengue-related medical emergencies.

Denouncing private hospitals without notifying the system to be followed by them is the best way of losing allies. The city has some 22 public sector hospitals and more than 30 hospitals in the private sector that have blood banks. At least, a third of all these hospitals could have been designated as nodal centres for providing blood components to attached satellite hospitals.

Undoubtedly public sector hospitals have to bear the brunt of epidemics, despite being over stretched even in normal times. But certainly more than 60 private hospitals in Delhi, which run emergency departments 24X7, can support them. Private hospitals cannot deny competence and refuse dengue patients. Most often, all that is required is to observe and interpret the vital parameters of a patient and provide immediate intervention. Checking blood pressure, administering intravenous fluids, assessing laboratory test results and getting fresh tests done are among the basics that any hospital claiming to run an emergency department has to provide. Hospitals which claim inability to perform these services should be directed to close down their emergency departments.

A canard is being spread that the government has no powers to enlist private hospitals. This is untrue. All private hospitals require a plethora of approvals from the government and they have to comply with a host of laws. As such they respect government authority and respond to reasonable appeals for short-term support during emergencies. No private hospital would wilfully risk losing goodwill by getting publicly shamed for callousness.

Every doctor wants to heal and emergencies often bring out their best. But for this to happen everyone in the hierarchy and in the wider network of health facilities must understand roles and responsibilities. Once they do that, written instructions need to be issued in simple, consistent and implementable language. Those links are missing today. Central monitoring of availability of beds and dengue admissions in designated hospitals would further promote quick response and accountability and the Union health ministry and the Delhi government need to jointly operationalise this. Most important, the network of emergency and tertiary facilities must be notified locality–wise, using all forms of communication.

Dengue management is comparatively routine work, but it can suddenly become complex and daunting. Unlike many other medical emergencies, dengue has the added disadvantage of becoming life-threatening just when signs of recovery show. So if a hospital (government or private) lacks the capacity to deal with a patient, there has to be a common protocol for transferring a case to another designated hospital. Otherwise the tendency to first refuse admission and then push less educated and poorer patients out will not abate.

This phenomenon was studied by the Law Commission, which gave a report in 2006 based on The Emergency Medical Treatment and Labour Act of the United States, also called the ‘Patient Dumping Law’. Once US hospitals too refused to accept poor or uninsured patients brought in an emergency medical condition. The Commission not only gave a comprehensive report on emergency medical care but also provided a model law for the use of state governments, including a protocol for transferring patients. The Delhi government would do well to adopt portions of the Bill. The Centre is unlikely to stand in the way.

Most importantly, without 24x7 political will to confront these challenges, prospects of overcoming dengue appear doomed, and mid-November is still a long way off.

Shailaja Chandra is former chief secretary, Delhi. The views expressed are personal.